How do you feel about the possibility of assuming responsibility

1-How do you feel about the possibility of assuming responsibility for diagnosing clients in your future career? (450 – 600 words)

2-Where do subjectivity and clinical judgment come into play in the process of diagnosis?

3-Are there any benefits of a formal diagnostic system for the counselor who is not required to give diagnoses? (450 – 600 words)

4-Can medical conditions affect the therapeutic process or treatment planning? Explain. (450 – 600 words)

What are some examples of medical conditions that would be important to monitor because of similar symptomology of mental health disorders? (450 – 600 words)

Is it appropriate for counselors to consult with a client’s medical doctor regarding medical conditions? (450 – 600 words)

5-What is your opinion of the DSM-5 evaluation system?

Is this a valuable resource for clinicians or does it foster a medical-model approach to counseling? (450 – 600 words)

Do you feel it captures enough information about a client and his/her situation? Is anything missing?

What about personal strengths and environmental resources? (450 – 600 words)

6-What are the possible ramifications if a practitioner incorrectly diagnoses a client?

7- Do you feel the DSM-5 adequately takes into account cultural factors that may influence diagnosis with clients from diverse ethnic, cultural and/or linguistic groups? (450 – 600 words)

15 CHAPTER

'ED-TALK K the Diagnosis affect the Diagnosis mind ( ponen by chalrean. Roff Learning Objectives L01 LO2 Discuss reasons counselors should know about diagnosis Understand the relationship between the DSM and the ICD Describe the definition of a mental disorder in the DSM-5 Comprehend the importance of cultural factors in diagnosis Distinguish between other specified and unspecified disorders LO3 L04 L05 LOG Understand that each disorder has specific criteria LO7 L08 Distinguish among the neurodevelopmental disorders Distinguish among the bipolar and related disorders Distinguish among the depressive disorders LOG L010 Distinguish among the anxiety disorders L011 Distinguish among the obsessive-compulsive and related disorders L012 Distinguish among the trauma- and stress-related disorders L013 Distinguish among the feeding and eating disorders L014 Distinguish among the elimination disorders L015 Understand gender dysphoria L016 Distinguish among the disruptive, impulse-control, and conduct disorders L017 Distinguish among the substance-related and addictive disorders L018 Distinguish among the personality disorders L019 Distinguish among the paraphilic disorders LO20 Understand other conditions that may be the focus of clinical attention L021 Identify instruments that can help with diagnosis 300 Chapter 15 Diagnosis 301 A few years ago, I worked with a woman who presented with anxiety issues particularly as they related to work. She had found that by counting by threes (i.e., 3, 6, 9, 12 ...) she often could reduce her anxiety. If she made a mistake or could L01 not come up with the next number soon enough she would have to start over, Sometimes she would need to count into the thousands before her anxiety would dissipate enough so that she could go to work. The reason she sought counseling is the time it took her to count by threes was increasing and she was often late for work. It was helpful to me as a counselor to recognize that she fit the symptoms of someone with obsessive-compulsive disorder. Once I correctly diagnosed her with obsessive-compulsive disorder, I could then survey the literature related to treating obsessive-compulsive disorder and select a treatment approach that was empirically supported. Therefore, having knowledge of diagnostic criteria really helped me be effective with this client because the treatment approach was very helpful and we were able to reduce her anxiety, and when she left counseling she had stopped the compulsive behavior of counting by threes. Although 25 years ago there was some debate on whether counselors should use the Diagnostic and Statistical Manual of Mental Disorders (Hohenshil, 1993), it is now com- monly expected that in most mental health settings, counselors will need to be skilled diag. nosticians. Some readers may be wondering why there is a chapter on diagnosis in a book on counseling assessment. The answer is that diagnosis is frequently part of the counsel- ing process and the clinician must assess the client in order to make a diagnosis. It is not unusual for an individual to have a mental disorder as around 25% of adults suffer from a mental illness (Center for Disease Control and Prevention, 2011). Furthermore, many counselors need to know about diagnosis as a mental disorder diagnosis has generally be- come mandatory if medical insurance is to reimburse a clinician or an organization for treatment. Although school counselors are typically not required to provide a diagnosis, often they work with children and adolescents who have been diagnosed or they need to be familiar with diagnosis to refer a student to a certain agency that specializes in treatment for certain diagnoses. Also school counselors frequently work in multidisciplinary teams, and they need basic information about diagnostic categories. Diagnostic systems are designed to provide a common language for professionals so that diagnostic terms have a unified meaning rather than individuals using their own unique definitions. For example, if I walked down the street and asked pedestrians for their defi- nitions of substance abuse, the definitions would probably differ dramatically. Some people may not consider consumption of a six pack of beer every night as an indication of sub- stance abuse; others may consider one drink per night to be substance abuse. For effective communication within a profession, there needs to be uniformity in definitions. Diagnos- tic systems attempt to provide a nosology, or nomenclature, for counselors, psychiatrists, psychologists, social workers, and other health and mental health professionals. Diagnosis should not be viewed as providing a punitive label but rather as providing a description of LO2 the client's symptoms that others can understand. In the United States, the most commonly used diagnostic system for mental disorders is the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders, which is in the fifth edition and is commonly referred to as the DSM-5 (APA, 2013). The DSM-5 is not the only diagnostic system for mental disorders available as much of the world uses the World Health Organization's International Classification of Diseases (ICD). In fact, there is a direct connection between the DSM-5 and the ICD-9-CM and the ICD-10-CM. In the DSM-5, both the ICD-9-CM and the ICD-10-CM codes are usually attached to relevant disorders. In the United States, clinicians will have used the ICD-9-CM 302 Section III Applications and Issues TABLE 15.1 Previous editions of the Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR (2000) DSM-IV (1994) DSM-IT-R (1987) DSM-11l (1980) DSM-11 (1968) DSM-I1952) codes through October 2015, and then after that all healthcare professionals will use the ICD-9-CM codes are listed first and then the ICD-10-CM codes follow and are enclosed ICD-10-CM codes. The DSM-5 lists both the ICD-9-CM and the ICD-10-CM codes; the in parentheses. For example, the codes in the DSM-5 for autism spectrum disorder are 299.00 (F84.0). Therefore, before October 2015, a clinician would report a diagnosis of au- tism spectrum disorder as 299.00 autism spectrum disorder; whereas after October 2015, a clinician would report F84.0 autism spectrum disorder. The organization of the DSM-5 was also designed to correspond to the structure of the ICD-11, which is scheduled to be released in 2017. The DSM-5 is the latest iteration of the Diagnostic and Statistical Manual of Mental Disorders, and Table 15.1 includes a listing of previous editions. Rather than focusing on changes in the DSM-5 as compared to earlier editions of the Diagnostic and Statistical Man- ual of Mental Disorders, this chapter will mainly focus on the content of the DSM-5. Let me start by acknowledging that I could have written an entire book describing the content of the DSM-5. This chapter is designed as an introduction to the DSM-5 that will briefly over- view disorders frequently seen by counselors. Each disorder within the DSM-5 typically involves polythetic criteria, with very specific criteria that must be met in order to merit a diagnosis. This chapter will not cover the specific criteria for each disorder discussed; rather the focus is on pointing the reader to certain common disorders within the DSM-5 and then encouraging readers to learn the specific criteria from the DSM-5. The creation of the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-5) occurred over 12 years and involved hundreds of people, mostly psychiatrists, in different work groups. The DSM-5 was designed so that there is a common nomenclature that all mental health clinicians can understand and that can aid clinicians in making reli- able diagnoses. The writers of the DSM-5 focused on the science related to the disorders and asserted that since the DSM-IV was published there has been, “real and durable progress in such areas as cognitive neuroscience, brain imaging, epidemiology, and genetics” (APA, 2013, p. 5), which influenced all of the working groups. Another common thread emerging from the workgroups is an understanding that the boundaries between many of the catego- rized disorders in the DSM-IV were more fluid and that some symptoms, in varying degrees of severity, may be present across many disorders. Therefore, there is a focus on a dimen- sional approach to mental disorders, which influenced the organization of the DSM-5 and resulted in some cross-cutting assessments that will be discussed later. For counselors very interested in diagnosis, I would also suggest that they read Morrison (2014). L03 DSM-5's Definition of a Mental Disorder It should be remembered that the DSM-5 is primarily used to diagnose mental disorders , and not every difficulty a client has should be considered a mental disorder. In using the DSM-5, the first step is to see if the client meets the definition of a mental disorder. All disorders included in Section II of the DSM-5 will meet the following definition Chapter 15 Diagnosis 303 of a mental disorder except for “Medication-Induced Movement Disorder and Other Adverse Effects of Medication" and "Other Conditions That May Be a Focus of Clinical Attention." The following is APA's (2013) definition of a mental disorder: A mental disorder is a syndrome characterized by clinically significant disturbance in an individual's cognition, emotion regulation, or behavior that reflects a dysfunction in the Mental disorders are usually associated with significant distress or disability in social, oc- psychological, biological, or developmental processes underlying mental functioning. to a common stressor or loss, such as the death of a loved one, is not a mental disorder. cupational, or other important activities. An expectable or culturally approved response . Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are pri- marily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above. (p. 20) It is sometimes difficult to determine if a client has a mental disorder, particularly when the presentation of symptoms is mild. A generic marker that clinicians can use is whether the disorder causes “Clinically significant distress or impairment in social, occupational, or other important areas of functioning” (APA, 2013, p. 21). Once the clinician determines that a client does have a mental disorder , then he or she can turn to the diagnostic criteria for specific disorders (e.g., attention-deficit/hyperactivity disorder) to determine if the cli- ent meets the criteria for that diagnosis. The DSM-5 makes it clear that accurate diagnosis requires training and good clinical judgment. Organizational Structure As the American Psychiatric Association and the World Health Organization began to re- vise the DSM and the ICD, both focused on improving clinical utility by examining which disorders are grouped together and the overall structure of these diagnostic systems. The decision was to organize these two systems based on well-replicated science on the rela- tionships among the diagnostic groups. For example, depression and anxiety have often been found to be co-occurring disorders so they are placed next to each other in the orga- nizational scheme of the DSM-5. The goal of reorganizing similar diagnostic groups was to increase clinical utility and to encourage researchers to identify the psychological and physiological cross-cutting factors that are not bound to strict categorical designations. It may be that the organizational structure of future editions of the DSM may change as new evidence is found. The DSM-5 is considered a “living document, which will be adaptable with new findings in neurobiology, genetics, and epidemiology. On the basis of current re- search, it was decided to organize the DSM-5 by “internalizing and externalizing disorders” and based on developmental and life-span considerations. The DSM-5 begins with disorders that are generally manifested early in life (e.g., neurodevelopmental and schizophrenia and other psychotic disorders). These chapters of the DSM-5 are followed by diagnoses that are more typically manifested in adolescence and early adulthood (e.g., bipolar, depressive, and anxiety disorders). In terms of diagnoses, the DSM-5 concludes with disorders that com- monly occur in adulthood or later (i.e, neurocognitive disorders). This organization struc- ture is designed to improve clinical utility by encouraging clinicians to strongly consider the client's developmental level. The same organizational structure has been taken whenever possible with chapters of the DSM-5, where those disorders usually occurring in childhood are provided first, followed by disorders occurring in adolescence and adulthood, and fi- nally with disorders that are typically manifested in late adulthood. Therefore, the overall organizational structure of the DSM-5 is as follows: neurodevelopmental disorders, inter- nalizing disorders, externalizing disorders, neurocognitive disorders, and other disorders. Table 15.2 provides a listing of the chapters included in Section II of the DSM-5. 304 Section III Applications and Issues

TABLE 15.2 Section II: Chapter Structure Neurodevelopmental Disorders Schizophrenia Spectrum and Other Psychotic Disorders Bipolar and Related Disorders Depressive Disorders Anxiety Disorders Obsessive-Compulsive and Related Disorders Trauma- and Stress-Related Disorders Dissociative Disorders Somatic Symptom and Related Disorders Feeding and Eating Disorders Elimination Disorders Sleep-Wake Disorders Sexual Dysfunctions Gender Dysphoria Disruptive, Impulse-Control, and Conduct Disorders Substance Related and Addictive Disorders Neurocognitive Disorders Personality Disorders Paraphilic Disorders Other Mental Disorders Medication-Induced Movement Disorders and Other Adverse Effects of Medication Other Condition That May Be a Focus of Clinical Attention (V-codes and Z-codes) L04 Cultural Issues According to the APA (2013), “mental disorders are defined in relation to culture, social, and familial norms and values” (p. 14). Hence, clinicians need to be sensitive to cultural is- sues when diagnosing clients. In Section III of the DSM-5 under Cultural Formulation, there is a discussion of culture and diagnosis, which includes the Cultural Formulation Interview (CFI). The CFI contains 16 questions designed to assist clinicians in obtaining pertinent information regarding culture. The CFI is best used with demographic information so the questions can be tailored to the specific client being assessed. Also in the Appendix of the DSM-5 is a “Glossary of Cultural Concepts of Distress," which describes common cultural syndromes, idioms of distress, and causal explanation that are relevant to clinical practice. Nonaxial System With the DSM-5, the counselor no longer has to provide a five-axial diagnosis . If you are not familiar with a five-axial diagnosis, then it makes it easier to learn the DSM-5 system. Previously different information was listed on Axes I, II, III, IV, and V (e.g., medical com continue to be reported; it just does not involve an axial system. I will use the ICD-10-CM ditions were listed on Axis III). Medical information, psychosocial, and contextual factors and the DSM-5 to demonstrate a diagnosis with a nonaxial system. F34.0 Cyclothymic disorder J30.9 Rhinitis, allergic 259.6 Low income